PC-ACE Pro32 ICD-10 Implementation Guide 6/18/2015

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1 PC-ACE Pro32 ICD-10 Implementation Guide 6/18/2015 Important: This document is to be used internally by PC-ACE Pro32 distributors as a testing and implementation guide. It is not to be made available to end users in this form. Introduction: The U.S. Department of Health and Human Services (HHS) has mandated that everyone covered by HIPAA must implement ICD-10 for medical coding on October 1, 2015 (delayed from the original October 1, 2014 transition date). ABILITY Network Inc. is committed to supporting ICD-10 in PC-ACE Pro32. This implementation guide will serve as our distributors' primary reference regarding ICD-10 support in the product, describing what we've implemented thus far as well as thoughts on what's yet to be implemented. We have introduced ICD-10 capabilities early enough that PC-ACE Pro32 could be used as a test platform for your internal ICD-10 implementation activities. This guide will be updated quarterly as needed to reflect the current state of ICD-10 support in the product. Current ICD-10 Development Status PC-ACE Pro32 currently supports ICD-10 diagnosis and procedure codes as appropriate on both institutional and professional claims, eligibility/benefit inquiries, and professional roster bills. Users have access to a new ICD-10 reference file which mirrors the existing ICD-9 reference file. Both versions of the ICD code sets will be available in the product until the ICD-9 codes are no longer needed. Lookups during claim entry are supported from either the ICD-9 or ICD-10 reference files as determined by the optional LOB/payer-specific ICD Version transition rules (described below). PC-ACE Pro32 can generate ANSI-837 (5010) and ANSI-270 (5010) transaction files which report ICD-10 diagnosis and procedure codes. Claim import support for ICD-10 codes is provided for ANSI-837 (5010) files, institutional UB-04 print-image files and professional CMS-1500 (Version 02/12) print-image files. System-level edits have been added to implement the ICD-9 to ICD-10 transition rules as described in CR7492. Generally, institutional inpatient claims with claim service THROUGH dates on or after 10/1/2015 must report ICD-10 diagnosis and procedure codes. Institutional outpatient claims and all professional claims must be SPLIT such that service lines with FROM dates before 10/1/2015 are billed separately from service lines with FROM dates on or after 10/1/2015. Claims with service line FROM dates before 10/1/2015 require ICD-9 codes, while claims with service line FROM dates on or after 10/1/2015 require ICD-10 codes. Thoughts on Future ICD-10 Enhancements It is still undecided whether or not mixed ICD-9 and ICD-10 codes will be allowed on the same claim. It appears that this decision will be left to the individual payers (e.g., Medicare will not allow mixed ICD versions). PC-ACE Pro32 does not currently allow mixed ICD-9 and ICD-10 codes on the same claim. This restriction will be relaxed if necessary. We welcome feedback from our distributors on these and any other ICD-10 related topics.

2 PC-ACE Pro32 ICD-10 Implementation Guide Page 2 A Note Regarding Provider ICD-10 Testing The information in this document is intended for distributor use only, and is too technical for the typical PC-ACE Pro32 user. ABILITY has developed the PC-ACE Pro32 ICD-10 Test Assistant Utility which allows PC-ACE Pro32 users to easily activate/deactivate ICD-10 test mode so they can participate in the scheduled Medicare ICD-10 testing weeks. Refer to the separate communication regarding this test assistant utility for additional information. Activating ICD-10 Capabilities for Internal Testing Purposes Depending on the PC-ACE Pro32 version in use, an activation step may be required before PC- ACE Pro32 will allow ICD-10 diagnosis and procedure codes to be used in the product. To activate the ICD-10 capabilities of PC-ACE Pro32, select the "File" and "Preferences" items from the toolbar's main menu. When the Preferences screen is displayed, immediately type the ampersand "&" (i.e., "<SHIFT>7") character to show the "System" tabs. Select the "System (3)" tab and check the "Enable support for ICD-10 diagnosis and procedure codes" option. Click the "OK" button to save this change. Remember that you will also need to configure the applicable Submitter record(s) for ANSI version 5010 errata output in order to use ICD-10 codes on claims. Configuring ICD Version Transition Rules The published ICD-10 implementation date is October 1, Covered entities will not be allowed to send ICD-10 codes on production claims for service dates prior to this implementation date. However, as distributors, you will need to be able to generate ANSI transactions containing ICD-10 codes long before this implementation date in order to support pre-rollout testing activities. As such, we have enhanced PC-ACE Pro32 with the flexibility to configure the choice between ICD-9 or ICD-10 codes based on an LOB-specific or LOB/Payerspecific basis. System-level ICD diagnosis and procedure code validation edits and ICD code lookups are driven by these ICD Version transition rules. The program will assume that ICD-9 codes are required prior to the 10/1/2015 transition date unless an ICD Version transition rule applicable to the claim's LOB/payer combination indicates otherwise. This capability in essence allows you to accelerate the requirement for ICD-10 coding to any date prior to 10/1/2015 in order to facilitate your testing. Configuration of the ICD Version transition rules is performed from a normally-hidden tab in the PC-ACE Pro32 preferences screen. From the program's main toolbar, select the "File" and "Preferences" menu items, and log in when prompted. Type the ampersand "&" (i.e., "<SHIFT>7") character and select the "System (3)" tab. You will see the following control group on this tab...

3 PC-ACE Pro32 ICD-10 Implementation Guide Page 3 Functionally equivalent configuration interfaces are available for institutional and professional/dental claims, respectively. If your custom build is licensed for institutional claims processing only, then the "Configure Rules" button for professional/dental claims will be disabled (grayed). Likewise, if your custom build is licensed for professional/dental claims processing only, then the "Configure Rules" button for institutional claims will be disabled. We will focus our discussion on the professional side. This same information is generally applicable to the institutional side. Click the professional/dental "Configure Rules" button to display the professional/dental ICD Version Control Settings configuration screen. Each entry in this list represents an ICD Version transition rule. The next screenshot depicts a hypothetical professional/dental ICD Version transition rule set chosen purely for training purposes (your list will probably be empty). While considering these hypothetical rules, remember that the default ICD version is assumed to be ICD-9 unless otherwise specified by the rules. During claim entry or processing, the applicable service date, the claim's line of business (LOB), and the Payer ID of the "submission" payer together determine which of these ICD Version transition rules is in effect, if any. For example, a professional Medicare (LOB = "MCB") claim with service line FROM dates on or after 4/1/2014 would be governed by the last rule in the list. A professional commercial claim (LOB = "COM") for Payer ID = "12345" with service line FROM dates on or after 4/1/2014 would reference the fourth rule in this list. A professional commercial claim (LOB = "COM") for any other payer with service line FROM dates on or after 7/1/2014 would reference the third rule in this list. Note: The ICD Version Transition Rules capability was originally designed to permit entry of a "Rule End Date" in order to support multiple ICD Version transition rules for a given LOB/payer combination. We have determined that there is no practical use for this end date, and therefore suggest that it always be left blank. These rules are best employed to provide a clean transition from ICD-9 to ICD-10 on a given transition date. Only one ICD Version transition rule is therefore needed per LOB or LOB/payer combination.

4 PC-ACE Pro32 ICD-10 Implementation Guide Page 4 Five ICD Version transition rules are defined in this sample list. Starting from the bottom, the last entry defines the ICD Version transition rule for professional Medicare claims (LOB = "MCB" ; all payers ; Type = PROF) with service line FROM dates on or after 4/1/2014. These claims are required to report ICD-10 codes. Medicare claims with service line FROM dates prior to 4/1/2014 are not covered by any rule in the list, and are therefore assumed to still require ICD- 9 codes. This rule has the effect of accelerating the ICD-10 transition date for MCB claims from 10/1/2015 to 4/1/2014 in order to facilitate testing. System-level edits will behave as if 4/1/2014 is the ICD-10 transition date for these Medicare claims. The fourth ICD Version transition rule applies to professional commercial claims (LOB = "COM" ; Type = PROF) for Payer ID = "12345". Commercial claims for this payer with service line FROM dates on or after 4/1/2014 are required to report ICD-10 codes. Commercial claims for this payer with service line FROM dates before 4/1/2014 are not covered by any specific transition rule, and are therefore assumed to still require ICD-9 codes. The third ICD Version transition rule applies to professional commercial claims without regard to the payer (LOB = "COM" ; all payers ; Type = PROF). This rule will be applied to commercial claims whose submission payer is not otherwise represented specifically by other transition rules in the list. In our example, this rule would apply to all commercial payers except Payer ID = "12345". Claims governed by this rule must report ICD-10 codes when the service line FROM dates are 7/1/2014 or later. Prior to this date, these claims are not covered by any specific transition rule, and are therefore assumed to still require ICD-9 codes. The second ICD Version transition rule applies to Blue Shield dental claims (LOB = "BS" ; Type = DENT) for all payers. The rule states that Blue Shield dental claims with service line FROM dates on or after 4/1/2014 must report ICD-10 codes. Prior to this date, Blue Shield dental claims are not covered by any specific transition rule, and are therefore assumed to still require ICD-9 codes. The first ICD Version transition rule applies to professional Blue Shield claims (LOB = "BS" ; Type = PROF) for all payers. The rule states that professional Blue Shield claims with service line FROM dates on or after 4/1/2014 must report ICD-10 codes. Prior to this date, professional Blue Shield claims are not covered by any specific transition rule, and are therefore assumed to still require ICD-9 codes. Editing for ICD-9 versus ICD-10 Diagnosis & Procedure Codes PC-ACE Pro32 uses the ANSI version defined in the Submitter reference file along with these ICD Version transition rules to determine which ICD version(s) is allowed on any given claim. The program then applies edits to enforce the applicable rules. For claims required to report ICD- 9 diagnosis/procedure codes, the following edits will be reported if the user attempts to use ICD- 10 codes Incorrect ICD Version for Diagnosis Code (NNNNN) [Must Be ICD-9 Version] Incorrect ICD Version for Procedure Code (NNNNN) [Must Be ICD-9 Version]

5 PC-ACE Pro32 ICD-10 Implementation Guide Page 5 Likewise, for claims required to report ICD-10 diagnosis/procedure codes, the following edits will be reported if the user attempts to use ICD-9 codes Incorrect ICD Version for Diagnosis Code (NNNNN) [Must Be ICD-10 Version] Incorrect ICD Version for Procedure Code (NNNNN) [Must Be ICD-10 Version] When no ICD Version rule is applicable, depending on the claim's line of business, the user may have the option to enter either ICD-9 or ICD-10 codes. When this option is available, the first code entered will determine which ICD version is being used. The edits will then fire to prevent the user from mixing ICD-9 and ICD-10 codes on the same claim. We encourage you to experiment with these ICD Version transition rules in order to understand their function and to familiarize yourself with the user experience. Simply click the "New" button to add a new rule, or select an existing rule in the list and click the "View/Update" button to make changes. Since not all fields can be modified in update mode, you will sometimes need to delete and re-add a rule to get what you want. The Start Date and End Date for rules defined for the same LOB or LOB/Payer combination must not overlap. When adding or modifying ICD Version transition rules, click the "OK" button on the configuration screen to save your changes and return to the ICD Version transition rule list. Click the "OK" button two more times to save the Preference changes and return to the main PC-ACE Pro32 toolbar. If you have made changes to the ICD Version transition rules, you will be prompted when exiting the Preferences screen to close and re-execute the program. IMPORTANT: Please follow this instruction in order to avoid confusion. The program will not fully recognize these ICD Version transition rule changes until the program is re-executed. This advanced ICD Version transition rule feature has been developed primarily to assist PC- ACE Pro32 distributors with internal ICD-10 testing activities. However, it is possible that you might decide to utilize this feature in the field to control ICD-10 readiness activities. If so, let us know and we will work with you to accurately define the desired ICD Version transition rules and then implement them in a quarterly update or service pack so that all distributed copies of the program will behave the same. Conclusion ABILITY is committed to assisting PC-ACE Pro32 distributors in their ICD-10 preparation, testing and rollout activities. Let us know if you have any questions or comments concerning this implementation or future ICD-10 enhancements in the product.